Editorial: Community Hospitals; Challenges and Change Ahead

In a region that values small, local enterprises, news that the Upper Valley’s many small hospitals are facing unprecedented pressure to transform themselves might, at first glance, be disconcerting. Because the economic spirit of our time seems to favor consolidation, it’s easy to assume that whatever role those hospitals play in the future will not be merely different, but diminished.

We’re not so sure, and we don’t believe change is necessarily a bad thing.

A number of factors are forcing smaller hospitals to rethink their operations, according to a Sept. 2 article by staff writer Chris Fleisher, including changes in federal reimbursement, the implementation of the Affordable Care Act and mounting pressure to restrain health care spending. Considering that their much larger counterparts, including Dartmouth-Hitchcock Medical Center, face a similarly unclear and tumultuous future, it would be strange indeed if the smaller players escaped unscathed.

“We recognize that the environment is changing,” Anne Holmes, chairwoman of the New London Hospital board, said in March at a public hearing. “Free-standing hospitals are pretty much alone in the world, and you really need to be part of a system.”

The system that New London chose to be part of is Dartmouth-Hitchcock’s. Pending regulatory approval, the community hospital and the much larger medical center will collaborate by sharing some resources such as billing services while also making complementary arrangements for delivery of care.

Other community hospitals are being forced to question whether they can continue to offer the full array of medical services they have long provided. That was the case at Valley Regional in Claremont, which decided at the end of 2011 to discontinue its birthing center — a decision made not just under financial pressure, but also because the number of births had dropped to the point where Valley Regional officials were concerned that they weren’t maintaining the volume necessary to ensure quality of care. Valley Regional CEO Peter Wright says complaints about that decision are still frequent.

Perhaps dropping a birthing center is particularly difficult for a community served by a small hospital — “I was born and raised in Claremont” is now a boast that will eventually die out — but any narrowing of options is likely to generate unhappiness. The vast majority of people in the Upper Valley probably can figure out how to get themselves to Dartmouth-Hitchcock for a knee operation or a diagnostic test, but many prefer the convenience, familiarity and more intimate atmosphere of their community hospital.

But it’s no longer clear the country can afford that luxury. It costs money to provide medical technology and personnel, and having a surplus of resources can prove wasteful in one of two ways: It can result in its inefficient use or, as research at the Dartmouth Institue has indicated, it can encourage providers to order unnecessary procedures. No doubt, residents on either side of the river might value being able to get a certain procedure performed at Mt. Ascutney if they live in the Windsor area or Valley Regional in Claremont, but does it really make sense to offer that service in both places when the two hospitals are located relatively close to each other? It’s not clear that it even makes sense to operate as many emergency departments as now exist in the region’s small hospitals, although federal regulations currently require that any hospital designated as “critical access” (and receiving higher reimbursement as a result) offer such service.

But reducing duplication doesn’t have to amount to a mortal threat to these hospitals. Dartmouth-Hitchcock CEO James Weinstein has for several years been advocating for better coordination of the regional network of health services in a way that minimizes duplication and, he says, doesn’t involve monopolization by his institution. Such coordination presumably would allow hospitals to play to their strengths by keeping and perhaps expanding services they have demonstrated adept at providing. It might also encourage community hospitals to explore what they can do to plug gaps in the current system. In that regard, Valley Regional is considering what it might offer by way of mental health care. Substance abuse treatment is another underserved area of health care that strikes us as a promising option for smaller hospitals.

In short, the need to control costs is so compelling that familiarity and marginal convenience no longer cut it as viable reasons for sparing hospitals from wrenching change. We assume small hospitals will continue to play a vital role in the future health system, but it will be one determined by the value they provide tomorrow, not what we expected of them in the past.

To the Editor: Not a day goes by without a report in the Valley News or another media outlet in the region about the relative “health” of our local community hospitals. Your recent Sunday editorial “Community Hospitals; Challenges and Change Ahead” perfectly sums up the issues we at Mt. Ascutney Hospital and Health Center in Windsor address each and every …